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August 2003 This month’s Pharmacology Consult is presented as part of the special August edition on the well baby visit. While pharmacotherapy issues may not be a major part of the well baby visit, the use of medications in specific circumstances in the care of infants deserves review. Medication use for diaper dermatitis, dehydration, and poison prevention will be the focus of this month’s column, as it may be reasonable to review these topics with caregivers at well baby office visits.
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Source: Susan Boiko |
Two agents commonly found in products and often recommended are zinc oxide and petrolatum. These agents may be the best skin protectants available. Skin protectants absorb moisture or prevent direct contact of moisture with the skin. Zinc oxide is an excellent protectant and also has mild astringent and antiseptic properties. It is available in numerous OTC products, such as Desitin. Zinc oxide is also available in generic formulations. Some product formulations combine zinc oxide with other non-approved ingredients, such as vitamins A and D, Peruvian balsam, aloe vera or glycerin. Products with these or other added ingredients should generally be avoided, as it is unknown if they contribute additional efficacy, their use may result in allergic reactions, and are likely to increase product cost. Plain, generic, zinc oxide (1% to 40%) may be one of the best products available for treating diaper dermatitis. A disadvantage of zinc oxide, as anyone who has applied it can attest to, is its thick and tacky nature (which in part relates to its efficacy). Mineral oil can be used to remove zinc oxide from skin when necessary.
Petrolatum is another excellent protectant, and is available in numerous OTC products, for use in the treatment of diaper dermatitis and other conditions. Petrolatum is probably most well known as Vaseline, yet is available as a frequently used base in various ointments. Plain, generic, petrolatum (white or yellow) is another product that can be recommended, and it is inexpensive. Because of the commonality of diaper dermatitis and the availability of products OTC, cost may become an important issue to some caregivers.
The powders talc and cornstarch may also be used to treat diaper dermatitis. Care needs to be taken when these products are applied, however, as the possibility of powder inhalation by the infant with subsequent respiratory difficulty may occur. When these products are used, caregivers should be counseled that the powder should be applied close to the body, while the product container is kept away from the infant’s face. The concern that some may have of cornstarch encouraging yeast infection development is unfounded. Talc or cornstarch should not be applied to broken or oozing skin, as caking may occur, potentially resulting in infection.
Although zinc oxide or petrolatum are most commonly recommended for the treatment of diaper dermatitis, products containing other ingredients listed in the Table may also be used. Published studies comparing these ingredients are rare.
Some ingredients should not be routinely used for diaper dermatitis. Benzocaine, a topical anesthetic, may be found in some products. It contributes no additional efficacy and may sensitize the skin. Topical antimicrobials and external analgesics (eg, phenol, menthol, methyl salicylate, capsaicin) are similarly not recommended. Some caregivers may also apply hydrocortisone cream or ointment, as it is available OTC and caregivers may believe it to be useful.
While the application of hydrocortisone may be beneficial for some infants, it should only be used under supervision of a pediatric clinician. It is possible for significant systemic absorption, with resultant adverse effects upon the pituitary-adrenal axis, to occur when hydrocortisone is applied topically. Significant absorption is possible because of the relatively large surface area of application and the promotion of absorption through the use of an occlusive dressing (ie, the diaper). Hydrocortisone products available OTC are labeled not to be used in patients under 2 years of age, to prevent independent use by caregivers.
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The frequency of gastroenteritis and dehydration in infants, in addition to the potential for systemic antibiotic use to result in gastrointestinal adverse effects, allows discussion of the use of oral rehydration solutions (ORS) to be considered during well baby visits. The beneficial effects of ORS are well known and have been well studied. The American Academy of Pediatrics recommends that ORS be the preferred treatment of fluid and electrolyte loss caused by diarrhea in children with mild-moderate (3% to 9%) dehydration (1996). Caregivers should be instructed not to give nonphysiologic solutions (eg, fruit juices) as these do not contain adequate amounts of electrolytes and are hypertonic, potentially furthering fluid losses. ORS contain adequate amounts of potassium, sodium, chloride, and base. These products are relatively isosmotic (250-310 mOsmol/L). By comparison, apple juice has an osmolarity of 730 mOsmol/L.
When using ORS, caregivers should be educated on their purpose and that ORS do not affect stool volume or duration of diarrhea. Without such counseling, caregivers may stop administering ORS, with the incorrect assumption that the primary role of ORS is to stop diarrhea. Because of the potential for frequent disorders resulting in dehydration in infants, it may be wise for caregivers to have adequate supplies of ORS in the home at all times. Relatively few ORS products are available, and any of these products may be effectively used. Generic products are available, which are likely to be less expensive. Some products are flavored (fruit, bubble gum), which may increase palatability. For older children, Pedialyte Freezer Pops are also available (grape, cherry, orange, blue raspberry).
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Counseling caregivers on poison prevention is likely a routine part of the well baby office visit, generally beginning at 6 months of age. It may be wise for clinicians to assess the potential for poisonings in the child’s home at each subsequent well baby office visit and to reeducate caregivers if necessary.
Although the use and efficacy of syrup of ipecac is somewhat controversial, the AAP continues to recommend that homes with infants and children keep some in their medicine cabinets, as do poison control centers.
Information and tips on how to poison proof homes are easily available through the AAP and poison control center Web sites: www.aap.org and www.aapcc.org respectively. Clinicians should educate caregivers that the poison control center (national toll free telephone 800-222-1222) always be called prior to giving a child syrup of ipecac. Its use may not always be necessary, or it may be contraindicated (eg, when a hydrocarbon substance is ingested). It is helpful to suggest that caregivers have the poison control center telephone number readily available and easy to locate at home.
Additional information to review with caregivers includes a lesson on the most commonly ingested medications that may result in significant morbidity – acetaminophen, salicylates, iron, and antidepressants. Caregivers may not be aware of the danger of acetaminophen or iron, because of their common use and perceived safety.
For more information:
- Padron VA. Diaper dermatitis and prickly heat. In: Beradi RR, ed. Handbook of Nonprescription Drugs. 13th ed. Washington DC: American Pharmaceutical Association, 2002:737-52
- Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis, American Academy of Pediatrics. The management of acute gastroenteritis in young children. Pediatrics. 1996;97(3):1-22
- Shannon M. Ingestion of toxic substances by children. N Engl J Med. 2000;342(3):186-91.
